Provider Demographics
NPI:1942318571
Name:GRAHAM, MARY ANN (MSRD LDN)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MSRD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION STREET
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-852-6175
Mailing Address - Fax:508-595-2941
Practice Address - Street 1:630 PLANTATION STREET
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605
Practice Address - Country:US
Practice Address - Phone:508-852-6175
Practice Address - Fax:508-595-2941
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
042472266OtherPRIVATE HEALTHCARE SYSTEM
042472266OtherTHREE RIVERS
LD0142OtherBLUE CROSS
67850OtherFALLON COMMUNITY HEALTH P
7856570OtherAETNA US HEALTHCARE
MT0708OtherMEDICARE B
AA16843OtherHARVARD PILGRIM HEALTHCAR
MT0708OtherMEDICARE B